Executive Positions with Managed Care Organizations - Southern California and Texas

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espsonia@pacbell.net 
Contact: Sonia Varian 
T 818.707.7118

VICE PRESIDENT OF MEDICAL AFFAIRS - TEXAS
Responsible for the organization’s clinical vision, philosophy and strategy. Oversee the medical management and quality improvement programs support of the organization’s strategic plan. Develop and present clinical vision to various public stakeholders both locally and nationally. Oversee and support the medical management structure, assuring high quality care and compliance with regulatory and accreditation requirements. Administrative oversight and accountability for the quality improvement department.
Knowledge/Experience:
Requires an unrestricted licensed Medical Doctor or Doctor of Osteopathy, board certification in Psychiatry required. Previous experience as a senior level medical position with a managed behavioral health organization is required. Prior experience as a Medical Director for an MBHO with Medicaid/Medicare programs is preferred. Experience treating or managing care for a culturally diverse population preferred. Experience with quality improvement for an organization as well as knowledge of certification/accreditation standards such as URAC, NCQA is preferred. Course work in the areas of Health Administration, Health Financing, Insurance, and/or Personnel Management is a plus.

V.P. SALES AND BUSINESS DEVELOPMENT - TEXAS
Oversee national Sales and Business Development
Experience with sales and business development activities in Medicaid/Medicare or public sector programs preferred. Master’s degree preferred. Behavioral Health experience is preferred
Requires a Bachelor's degree in Business Administration, Public Health/Administration or equivalent. Experience in healthcare sales/business development or with complex, consultative sales of programs/solutions to government entities.

• Responsible for developing new market initiatives, assessing new markets, analyzing business opportunities and driving sales process to expand the business unit.

• Develop and oversee plan for government relations support as it relates to program strategies and market introductions; manage relationships with government officials to advance the company’s position.

MEDICAL DIRECTOR - HEALTH PLAN - SO. CALIFORNIA
Under the supervision of the Associate Chief of Managed Care, the Medical Director, Managed Care, is responsible for the appropriateness and quality of medical care. The Medical Director shall develop processes for medical reviews for coverage determinations for medical services and participate in the grievance and appeals process. The Medical Director shall provide guidance to health plan quality improvement, utilization management, as well as continuous measuring, monitoring and improvement of the health delivery system for plan members. Participate in strategic planning efforts for the Managed Care Division with respect to medical aspect of the health plan.

• Maintain knowledge in general medicine and disease specific national guidelines.

• DM utilization review and care management programs.

• Assure members receive quality, medically necessary care that balances individual need with cost effectiveness.

MANAGER OF CLAIMS - HEALTH PLAN - SO. CALIFORNIA
Align the daily operations of the Claims Department with the strategic direction of the organization.
Clearly define department goals and focus staff upon these goals.
Build supportive, team-oriented environment for the staff through embodying a sense of empowerment, demonstrating positive thinking and establishing common goals and interdependence with employees.
Manage corrective actions in accordance with Quality Management or Compliance Department instructions, and Federal or State guidelines and expectations.
Review all department operating procedures & policies on at least an annual basis & recommend any necessary revisions or additions as necessary.
Draft operating procedures, policies & procedures for review & approval by appropriate Committees, Management.
Supervises Claims Examiner(s), Senior Claims Examiners, temporary Claims staff & administrative support staff. Carries out supervisory responsibilities in accordance with policies and applicable laws.
Minimum one (1) year experience with supervisory position in a Health Plan claims department.
Proven experience in customer service.
Thorough knowledge of claim procedures, policies, terminology, federal/state statutes & guidelines, including extensive knowledge of Medicare & Medicaid payment methodology.
The ability to operate PC or network based claims software programs, proficiency in Microsoft Word & Excel required.
Experience with EZ-CAP Claims Adjudication software preferred.
Advanced technical proficiency with medical terminology, all standard medical coding guidelines (CPT, HCPCS, ICD-9, ICD-10 when applicable, Medicaid Local Codes, Modifier Codes) & all Medicare & Medicaid Payment Guidelines or general claims payment guidelines & practices including Medicare DRG based Prospective Payment systems (PPS), Medicare Part B vs. Part D billing & payment guidelines, Medicare Ambulatory Payment Classification PPS, Medicare Home Health PPS, Medicare Skilled Nursing Facility PPS, etc.

Certificates, Licenses and Registrations
Valid California Driver License.
 

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